Migraine in Children

Migraine is the recurrent headache that develops with or devoid of aura and persists in children from half an hour to 48 hrs. It is the most frequent cause of main headache in young children. It differs from migraine in adults and will probably be underdiagnosed.

Although there tend to be many common characteristics with adult migraine, this article features aspects important throughout childhood migraine.

Epidemiology

Migraine is rare under the age of two years but 20% have a very first attack under the age of five years. It is more usual in boys compared to girls until after menarche, when it becomes more usual in girls.
The prevalence of adolescent migraine was found being almost 8 in each 1, 000 in the united states. This looks rather low. Another European research found a one-year frequency of 7% within students aged 13-18 years.

Classification of migraine

Childhood migraine may present in a similar fashion to migraine in adults but non-headache as well as neurological symptoms (aura) might be more prominent compared to a headache. No formal category of headaches distinct to children exists. The International Classification of Headache Disorders (ICHD) from International Headache Society (IHS) identifies migraine and acknowledges the childhood variations in its category:

IHS Classification which includes variants (a few rare) observed in childhood:

Migraine without aura – the most frequent variety in children and adults.
Migraine with aura – 14-30% of migraine in young children and including:
Aura without headache – more usual in childhood.
Hemiplegic migraine – more usual in childhood.
Basilar migraine – more usual in childhood, particularly in girls that are young.
Ophthalmoplegic migraine — very rare but more usual in children in comparison with infants, and even rarer within adults.
Acute confusional migraine – observed in childhood.
Childhood periodic syndromes, commonly precursors of migraine and virtually exclusively confined to childhood, including:
Cyclical vomiting.
Abdominal migraine.
Benign paroxysmal vertigo of childhood.
Retinal migraine : seen more within children and in 16 and up.
Probable migraine.
Complications of migraine.

Presentation and analysis

The diagnosis within children is more challenging because:

The condition is actually defined by very subjective symptoms.
The prominence of non-headache symptoms.
The increased likelihood that it’s a new medical diagnosis.

Any difficulty with diagnosis can aggravate parental anxiety.
Modified IHS requirements (note reduced duration from grownup 4-72 hours)4
IHS criteria for the diagnosis of migraine devoid of aura under 14 years. IHS criteria for the diagnosis of migraine having aura under 15 years.
Five attacks of headache lasting half an hour to 48 hrs. Headaches meet a minimum of two of these kinds of criteria:

Nausea, vomiting or the two together.
Photophobia, phonophobia or the two together.

Two attacks with a minimum of three of the subsequent:

One or more fully reversible aura symptoms including brainstem dysfunction, focal cortical or even both.
At least 1 aura symptom which develops gradually over more than four mins or 2 or more that occur in succession.
No aura signs and symptoms lasting >60 min’s.
Headache follows aura within 60 min’s.

Clinical scenarios

Preschool children having migraine may seem ill with stomach pain and nausea relieved by sleeping.
Preschool children might exhibit pain along with changes in habits (irritability, crying, seeking out some sort of darkened room).
5-10 year-olds frequently have bilateral pain together with abdominal cramps as well as vomiting. They usually sleep in an hour of onset.
Location and depth of headache might alter within as well as between attacks.
Intensity and length of headache enhance with age and turn more usually unilateral.
A family background is common within migraine patients.

Migraine without aura

Most migraine (around 80%) is of the type. It is well worth reviewing with parents the common phases of the attack, so that alterations in behaviour and mood could be put into the situation:

Premonitory symptoms (modifications in mood, appetite, thirst, arousal, etc. ).
Headache lasting half an hour to 48 hrs in children. This may be the only phase which the patient is aware of. In children the pain might be bilateral and isn’t always throbbing or even pulsating in dynamics.
Accompanying symptoms occur and therefore are prominent in children – for instance, sensitivity to light (photophobia), sounds (phonophobia) as well as smells, tiredness, gastrointestinal disturbance, etc.
Postdromes (exhaustion, depression).

Migraine with aura

14-30% of migraine throughout children is of this type. The aura might follow premonitory symptoms and might or might not be followed by headaches.

The aura might suggest cortical disorder (visual, sensory, motor, speech or vocabulary disturbance, cognitive impairment such as confusion), or brainstem dysfunction (decrease of vertigo, onsciousness, ophthalmoparesis).
Children may find it hard to describe the aura.
The aura is frequently more distressing {compared to theeadache in children.
Visual auras are the most frequent (blurred eye-sight, fortification dysmorphopsia, spectra, micropsia, scotomata, macropsia, etc.).
Children who ultimately develop migraine experiencing aura usually present sooner than children experiencing migraine devoid of aura.

Some of the less common migraine variations are listed to help illustrate diagnostic issues and, invariably, they require professional referral:

Aura without headache

Visual auras are known as the most frequent.
Consider other diagnoses, especially if never accompanied by headache.

Hemiplegic migraine

A dramatic demonstration.
Hemiplegia or hemiparesis might precede or go along with the less spectacular headache.
There is usually a family history.

Basilar migraine

Aura followed by symptoms like dizziness, syncope and a little headache.
Most often observed in adolescent girls.

Ophthalmoplegic migraine

Disorders of eyes movement or pupillary reaction precede the headache.

Acute confusional migraine

Migraine before as well as following transient attacks of amnesia, confusion and significant aphasia or dysphasia subsequent to minor head injury.

Childhood periodic syndromes

Childhood periodic syndromes in many cases are a precursor to migraine but may present a diagnosis challenge and require specialist referral. These include:

Cyclical vomiting along with migraine (regular syndrome). This is characterized by recurrent attacks of intense nauseaor vomiting occurring often throughout the night and with complete recovery between attacks. Girls are far more affected. Stress and dietary triggers might be identified. It typically starts in toddlers and also resolves by age of puberty.
Abdominal migraine. This presents generally as recurrent rounds of generalised abdominal pain linked to vomiting and nausea but no headache, followed by sleeping and recovery. Typical migraines might occur separately.
Benign paroxysmal vertigo appears usually from age group 2 to 6 years and it is characterised by short episodes of vertigo and nausea without hearing loss or decrease of consciousness. More common migraine eventually ensues but suggestion to exclude posterior fossa tumours is needed.

Differential diagnosis

As can be appreciated through the wide variation in presentation of migraine in addition to migraine variants, there is theoretically a long as well as varied list. However, other possible diagnoses could be grouped under the subsequent:

These may follow history and evaluation (including fundoscopy as well as head circumference). Further investigation isn’t normally necessary however it’s indicated, for example, if:

Neurological examination will be abnormal (continual focal signs or perhaps papilloedema).
There is a brief history of seizures.
There is a brief history of head injury.
There has been a substantial unexplained change within the pattern of headaches.

Associated diseases

Asthma, allergies, motion sickness and also seizure disorders are more common in migraine patients.

Management

The principles resemble those in grownup migraine management. Important differences is usually highlighted:

Conservative management alone is more frequently effective.
Reassurance of parents is usually an important part of management.
Drug dosages and contra-indications are wide and varied.
Children with migraine not responding to trigger avoidance and also simple analgesics along with or without anti-emetics ought to be referred to a paediatrician with an interest in headache.
Management in children involves all the family.

Prognosis

Generally, migraine improves with age and frequently abates temporarily all around adolescence. Approximately 50% will keep having migraines further in life..